EUTHANASIA - THE PSYCHOLOGICAL ASPECT

Having examined some of the reasons to introduce Euthanasia, it is essential that the government, along with the rest of the legislators do take the psychological effects into consideration. This is especially so since one would be taking a decision which in itself is irreversible. Accordingly they should be well aware of what they are about to face and what is ahead for their next of kin.

The effects of euthanasia are mostly felt by the family and the physician 1 assisting the patient who is opting for Assisted Suicide or Euthanasia, in order to prepare the patient for what is to come, even more so if said patient has a fast-deteriorating medical condition.

The psychology of the patient and its understanding is an essential because they are the individuals who must be prepared for the con sequences that will ensure.

However what is interesting to note is that the patient most of the time is ready to take on the necessary steps, though at times there are some patients who look into the option of euthanasia as an idea

1Also referred to as PAS - Physician Assisting Suicide

or process which provides comfort. It provides comfort duly because they are aware that this option is a means and a way which is available to them, should their suffering become too much to handle. It is in fact because of this that studies carried out over the years have shown that most patients tend to apply for the medicine which help in the comfort of the patient, but rather ask for mediine that actively leads to their death.

To be able to understand such effects we shall be taking the example of two main states - The Netherlands and the United States 2 .

THE NETHERLANDS

Over the years euthanasia has come to force even more often in the Netherlands, which however have led to several cases like the one underneath:

‘I was giving consultations in several situations like this, when the GP was calling me about a patient with gastrointestinal obstruction. He said, The problem is that the patient is refusing euthanasia.’ I said, ‘What happened?’ He said, ‘In the past, all these kinds of situations, when people were intractably vomiting, I solved by offering eutha nasia. Now this patient does not want it, and I do not know what to do.’ That was really striking. Providing euthanasia as a solution to every difficult problem in palliative care would completely change our knowledge and practice, and also the possibilities that we have . . . . This is my biggest concern in providing euthanasia and setting a norm of euthanasia in medicine: that it will inhibit the development of our learning from patients, because we will solve everything with euthanasia.”

THE UNITED STATES OF AMERICA

Another Country wherein the process of Euthanasia is carried out in few of the states 3 in the United States, the same country which has been at the forefront of medical innovation and vast research. Even in a country like the U.S,. the physician still goes on to present an argument similar to that presented by the Dutch. It therefore means

2Reference: http://www.pccef.org/articles/issues_law_medicine_stevens_article.pdf 3 These states are; California, Colorado, Oregon, Vermont and Washington.

that just like the Dutch, the Americans physicians are concerned that the patient is in fact treated objectively rather than subjectively, that euthanasia will be the solution offered to each patient suffering from a terminal illness as a carte blanche option, rather than on a case-bycase basis. This may inhibit the development of medical innovation, medical research and the necessity of development in bio-medical science, without mentioning the averse effects caused to the human psyche.

Having said that, it is also interesting to note that even though the same physicians are concerned with a possible lack of development in the medical sphere, 53% of those physicians performing Euthana sia find comfort knowing that their patient did not suffer. This was an outcome of a survey carried out following the enforcement of the DWDA of Oregon in 1994 4 , thus making Oregon the first State in the U.S. to support Euthanasia in their law and medical practice. 5

In a structured in-depth telephone interview survey of randomly se lected United States oncologists who reported participating in euthanasia or PAS, Emanuel reported 53% of physicians received comfort from having helped a patient with euthanasia or PAS, 24% regretted performing euthanasia or PAS, and 16% of the physicians reported that the emotional burden of performing euthanasia or PAS adverse ly affected their medical practice.

In a mail survey of physicians who had acknowledged performing PAS or euthanasia, Meier reported the following responses pertain ing to the most recent patient who had received a prescription for a lethal dose of medication or a lethal injection among the 81 physi cian respondents (47% were prescriptions, 53% were injections): 18% of the physicians reported being somewhat uncomfortable with their role in writing a prescription, and 6% were somewhat uncomfortable with the lethal injection; <1% were very uncomfortable with their role in writing the lethal prescription, and 6% were very uncomfort able with the lethal injection.

The emotional trauma experienced by some Oregon doctors is noted in the following responses obtained in Oregon in December 2004 by the British House of Lords committee:

4In 1998 the first case of effective Euthanasia in Oregon and subsequently in America was performed 5 The Oregon Death with Dignity Act, which legalises physician-assisted dying with certain restrictions, making Oregon the first U.S. state and one of the first jurisdictions in the world to officially do so. The measure was approved in the 8 November 1994 general election in a tight race with the final tally showing 627,980 votes (51.3%) in favour, and 596,018 votes (48.7%) against.[11] The law survived an attempted repeal in 1997, which was defeated at the ballot by a 60% vote.[12] In 2005, after several attempts by lawmakers at both the state and federal level to overturn the Oregon law, the Supreme Court of the United States ruled 6-3 to uphold the law after hearing arguments in the case of Gonzales v. Oregon.

Question by Baroness Finlay: ‘In a conversation after we had taken evidence this morning from David Hopkins, he said that, at the beginning, he had the feeling that doctors needed to tell the whole story because they were very traumatised by having been involved, but that, in the last year, that is not happening as they have become used to it. I won dered whether you felt that was echoed within your research.’

Response by Dr. Goy: ‘Again, anecdotally, yes. This was a monu mentally difficult experience for a doctor early on, even considering changing the direction of care from preserving life and extending life to helping someone end it. For many, they have done it maybe for one patient and cannot reconcile that they have done it and they are very uncomfortable with it.’

Another physician went on to explain that he finds it strange to com prehend the eventuality that the patient becomes a subject of death, from a family person, and one surrounded by people who love him. A person that he was once getting familiar with, to an individual whose death is written on paper following his specific with to die in peace.

Following an analysis of the psychological and emotional pain that physicians perform assisted-suicide, one may come to conclude that the physician is centrally involved in PAS and euthanasia, and the emotional and psychological effects on the participating physician can be substantial. The shift away from the fundamental values of medicine to heal and promote human wholeness can have signifi cant effects on many participating physicians. Doctors describe being profoundly adversely affected, being shocked by the suddenness of the death, being caught up in the patient’s drive for assisted sui cide, having a sense of powerlessness, and feeling isolated. There is evidence of pressure and intimidation of doctors by some patients to assist in suicide. The effect of countertransference in the doctor-pa tient relationship may influence physician involvement in PAS and euthanasia. Furthermore, the many doctors who are participant in Euthanasia and/or are adversely affected emotionally and psycho logically by their expenses.

It is found that the doctors describe their patients as very forceful and adamant on their request for assisted suicide, even in those cases where in the physician is unwilling to participate, to the extent that in itself the majority of patients want the medicine rather than its administration. This is even more so because many patients have a common belief that the simple possession of such a medical cocktail is an option to end their suffering. Even though this is the case, doc tors report that in countries wherein the medicine is handed out to the patient, the same individual may not necessarily decide to use this option.

In those cases wherein the doctor chooses to refuse to be part of this procedure, patients may tend to perceive the medical practitioner as an obstructionist and become quite resentful towards him/her.

Emotional experiences for psychiatrists who are called upon to eval uate potential assisted suicide patients’ mental competency, appear to be more genuine, concerning and profound when they disqualify patients. Where the physician decides to disqualify patients, there is an extraordinary pain for the patient and the family alike because they have an understanding that euthanasia will help resolve emo tional issues, rather than complicate them. An example of such anger was energetically expressed by Kate Cheney, 6 an Oregon PAS Patient whose evaluating psychiatrist had told her; ‘You cannot make the decision for yourself and your life, because you are not in your right mind.’ To which the patient responded ‘Get out of my house you have no right to tell me this!’ The same anger expressed by the patient was also expressed by her daughter who in turn made it clear that this should be her mother’s choice as she was the individual who knows what she is feeling.

Physician participation in assisted suicide or euthanasia may have a profound harmful emotional toll on the involved physicians. Doctors must take responsibility for causing the patient’s death, thus creating a huge burden on the physician’s own conscience, tangled emotions and a large psychological toll on the participating physicians. Many physicians describe feelings of isolation, or ingraining the likelihood of patients and others to pressure and intimidate doctors to assist them in suicides. Some doctors feel they have no choice but to be in volved in assisted suicides. Oregon physicians are decreasingly pres

6B. C. Lee, compassion in dying 77 (2003) (As related by Kate Cheney’s daughter, Erika, in chapter entitled “Kate Cheney”)

ent at the time of the assisted suicide. There is also great potential for physicians to be affected by countertransference issues in dealing with end-of-life care, and assisted suicide and euthanasia.

These significant adverse ‘side effects’ on the doctors participating in assisted suicide and euthanasia need to be considered when discuss ing the advantaged and disadvantages of legalisation.

A patient seldom comes to a physician to request assistance with suicide unless the decision has first been discussed within the family, or unless the family setting has in some way influenced the deci sion. Advocates of legalising physician-assisted suicide tend to view the family relationship among the potential safeguards which assure that a right to suicide assistance will not be abused. Presumably the family will help to assure that the patient’s choice is truly voluntary and that the patient has appropriately sought out other care options before concluding that death through suicide is the only effective way to avoid further suffering. While admittedly some families are abusive or neglectful, proponents assume that other safeguards, such as mandatory mental health evaluations, will successfully identify these exceptional cases.

By contrast, opponents of physician-assisted suicide tend to assume that the family’s influence will make it highly likely that the patient’s choice of death cannot truly be said to be ‘rational.’ Since caring for a person with a terminal or incurable disease is extremely econom ically straining, the family will almost inevitably come to harbour wishes that the patient’s death will occur sooner rather than later so that their ordeal may end. Even if these wishes are consciously suppressed or denied, they may subtly influence the communication between the family members and the patient. The end result may well be that the patient will come to feel that his life is no longer worthwhile, and that he would be performing an act of generosity toward his family were he to speed up the process of his dying.

Euthanasia is unlike normal suicide, and this is mainly because in a typical case of suicide, the surviving family members experience anger and prolonged, abnormal grieving, leaving a lot of unanswered questions and a feeling of loss through the notion that one might have failed to notice those signs which were evident. Euthanasia on the other hand is such a case wherein the family is well aware of the patient’s wishes along with the fact that this wish is to be expressed solely at his discretion, even though as has previously been outlined

the family may indeed have an effect on the final decision taken by the patient. This is even more so when the patient wants to relieve the family of added burden, though this might not always be case or thoughts of the family members.

Physician assisted suicide is unlikely to yield feelings of anger or re jecting action directed at themselves. Perhaps this is because in this particular scenario, at this point the patient is suffering of a terminal illness thus making his or her death far more understandable than suicide which is triggered by depression or any other mental illness, or in part because the individuals being feel a sense of comfort in knowing that the physician will be participating, making it more ac ceptable. Acceptable to both family and society as a whole.

Therefore, though euthanasia in itself is a difficult process the family tends to take an empathic and sympathetic approach to what the pa tient might be passing from, whilst trying to fulfil their wishes in the best way possible. Furthermore, the same members will try to ease the suffering of the patient, a view point taken in the best interest of all parties involved.

The Psychological aspect of Euthanasia, is a vital aspect to consider as the analysis presented rigorously shows. It is necessary to draft such a law or policy which may express the opinion of the general public.

Furthermore, such an assessment is mandatory when drafting a pol icy in this regard duly because the psychology of it is an essential part since all parties involved can be effected directly by it, from physicians to people close to the patient along with the patient himself or herself. It is because of this that in the proposals to follow in this policy paper we have proposed matters directly linked to the psyche of the patient, a mental state which needs to be evaluated as it helps determine whether or not the express will of the patient is to be take into consideration and thereby executed.

Euthanasia is and always will be a topic which yields moral debate, though it is a subject which legislators must debate due to the pro gress of time, of medicine, and of law. A debate that can help prove vital for the formation of a law, above all it help set a clear line as to whether the introduction of such a law is necessary - especially since people, as is the case in Malta, directly plea to the government and law makers to implement it.